Why the American problem with opioids and chronic pain is here to stay

America consumes 80% of the world opioid supply (99% of the world hydrocodone supply), but has about 5% of the world’s population. If you don’t think America has some kind of opioid problem, then move along because this rational, evidence-based, experience-laden way in which I’m going to discuss opioid use and misuse will not interest you.

To combat our opioidification the Food and Drug Administration has recommended prescribing restrictions on hydrocodone (remember, we consume 99% of the global hydrocodone supply). These obstacles do not appear derived from evidence-based guidelines and probably won’t do much to reduce the vast majority of inappropriate prescribing, although they may slightly curtail physicians that run pill mills and may also help with diversion (lying to get opioids to sell them on the street).

But I want you to consider these following pain scenarios, because this is how the majority of opioids are prescribed in the United States. In each scenario there is a patient with chronic low back pain who started taking a Norco (acetaminophen and hydrocodone) every day or two for her pain, but now four years later is taking 8 Norco a day.

Patient A was never referred to physical therapy, never prescribed an adjuvant medication for chronic pain (adjuvant medications treat the way chronic pain is produced in the nervous system), never given a graduated exercise program, never had her anxiety or depression discussed never mind treated, and never given the option of a long-acting opioid. In short, she was only ever offered one therapy, the wrong one. Over time, her pain worsened (a natural consequence of untreated depression, anxiety, and immobility) and she needed more Norco a day.

Patient B was offered all the above therapies and they were well-covered by her insurance, but she found reasons to cancel physical therapy at the last minute, was intolerant of every medication except the Norco, and refused to speak with a pain psychologist despite being profoundly depressed (PHQ-9 of 24) and suffering from an anxiety disorder. Over time her pain worsened and she needed more Norco a day.

Patient C wants to go to physical therapy, but the co-pay is $80 so even twice a month isn’t possible (a month of Norco costs $5). She is dutifully doing her home exercises, but often does too much and pays for it in pain the next day because learning pacing from a pain psychologist isn’t a covered benefit. She is open to addressing her depression and anxiety, but don’t have mental health coverage. She tried nortriptyline (the only truly low-cost adjuvant medication for chronic pain, $4 a month via WalMart), but it was ineffective. Generic gabapentin, the next generic that is offered (because brand name drugs are prohibitively expensive under her health plan) is $1 a pill and that will be about $180 a month. She would love to do Tai-Chi or restorative Yoga to get moving, but can’t afford it. Over time her pain worsened and she now needs 8 Norco a day.

Patient D had an MRI when she complained of back pain. A bulged disc was identified. After 2 epidurals that didn’t work (no PT or other multidisciplinary approach was offered), she had back surgery. When, after a brief 4 month post surgery respite, the pain worsened she had more epidurals and another surgery with a multi level fusion. And then another one. Over time her pain worsened (she now has failed back syndrome) and she takes 8 Norco a day

Despite the fact that opioid monotherapy is sub-optimal care, it happens all the time. I’m not sure how the FDA restrictions will help a doctor, who has less than 15 minutes and may not fully understand the multidisciplinary approach required to address chronic pain, delve into anxiety, depression, physical therapy, cognitive behavioral therapy, weight loss, pacing, adjuvant medications, nerve blocks, dietary modifications, and the appropriate use of opioids (just to name a few therapies).

Non-compliance is a challenge in all aspects of medicine, and chronic pain is no different. However, the availability of opioids as a potential therapy certainly confuses things. A beta-blocker for high blood pressure has no component of secondary gain. How do we approach non compliance in chronic pain when opioids are on the table? We know that exercise and physical therapy reduces both pain and work disability for many patients with back pain and are the standard of care, but what if a patient is less than compliant with physical therapy or flat-out refuses yet shows up on time for her opioid prescriptions? Non compliance isn’t limited to physical therapy or exercise either. How will the FDA restrictions guide clinicians in these scenarios?

In almost every single health plan in the United States it is easier to get an MRI and back surgery than it is to get physical therapy. FDA restrictions will not solve this problem.

In the United States there is a reluctance to accept that the mind-body connection is a huge part of the pain equation. The neurochemical changes of depression and anxiety increase pain, because the same chemicals released by an anxious or depressed nervous system are the very same chemicals that produce pain. Basically, depression and anxiety fuel the fire of pain. How will the FDA regulations fix this mind-body disconnect (among both patients and providers ), solve mental health parity, and break down the stigma of mental health?

What if the patient actually has access to and wants to go to a cognitive behavioral therapy program, but she works two jobs and can’t afford to take the time off to go? After all, most of these programs are offered during the day. How will the FDA restrictions help in this scenario?

There are only a few generics for the medications that can actually treat chronic pain, so most of these drugs are very expensive. Many opioids are as cheap as M & Ms. A few extra hoops for hydrocodone won’t solve this issue.

Some docs have admitted to essentially giving Vicodin goody bags to improve Press Ganey scores. Yes, you read that correctly. Check out that link at the peril of your sanity. There is a push to give the patient what they want, which may not always be the standard of care. And yes, many people want opioids. How will the FDA restrictions put the brakes on this trend?

And finally, we practice medicine in a world where some chronic pain conditions respond suboptimally to evidence-based therapies and appropriate, responsible opioid prescribing may be a necessary component.

I practice in chronic pain Nirvana. Everyone of my patients has access to skilled physical therapy, adjuvant medications, a pain psychologist, and a psychiatrist, although rising co-payments are eroding away at the way people can practically access these services. We have intensive cognitive behavioral therapy programs designed to get the immobile moving (immobility is the nemesis of chronic pain, a self-fulfilling prophecy). We even have Tai Chi and Feldenkrais. And yet, sometimes even when we harness all these treatments we still need opioids (although almost always we are able to lower the dose). And sometimes, patients decline all these therapies and only want opioids.

Proposing restrictions helps us think about opioid misuse and abuse, which is good. New York City’s decision to limit opioids prescriptions from the emergency room to a three-day supply is a more thoughtful approach, although not perfect. Chronic pain shouldn’t be managed in the emergency department, although what happens to the patient without insurance who goes to the emergency room for her pain because she knows she won’t be turned away? Should this patient be treated differently than the patient who is going to the emergency room to get Dilaudid (hydromorphone) hoping that her doctor, with whom she has a pain contract, won’t find out?

Requiring a new written prescription for hydrocodone every 30 days probably won’t change too much. Some doctors, to avoid the hassle, might refer a little sooner to pain programs (which will be good, if such a program is available) or to a surgeon (in general less good for chronic pain, but always available). Some doctors may refuse to start opioids (good for some patients and bad for others), but many doctors will probably just leave written prescriptions with their receptionists for their patients to pick up. In summary, the American problem with opioids and chronic pain will remain unchanged.

Why the American problem with opioids and chronic pain is here to stay 42 comments

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kellylatta

Dr. Gunter makes some excellent points about the need for comprehensive care. Unfortunately too many doctors also go the other way dumping pain patients off as psychosomatic because they either don’t take the time to work with the patient, misdiagnose the source of the pain, or they are uncomfortable acknowledging the lack of effective treatments and lack of knowledge about pain. Although depression is a very normal reaction to chronic pain and definitely must be treated, it doesn’t make the pain psychosomatic.

The DSM 5 will now allow such patients to be labeled with Somatic Symptom Disorder (basically a new name for psychosomatic) if in the opinion of the doctor or psychiatrist not experiencing the pain the patient has excessive concerns or reactions to the pain. Being mislabeled with a mental illness will only exacerbate the situation further.

drg

A fantastic article that really thinks through why there is such a problem with treating pain. One of the first I have read. Although the problems with pain patients are too diverse. There are all kinds of reasons why it is more complicated to treat. But as the article writes, not impossible. Yet there are so many hinderances to care that the current system is just not set up to treat pain. It takes about 3 months to get into see a specialist in many academic centers. All the delays and disorganization that pts experience just weaken the patient and precipitate depression feeling so helpless.

The healthcare system wants to make money the way they want to make money. That is the fundamental problem you have pointed out. Meaning, profit comes before care. pharmaceutical companies have enormous power so of course opiates are a money maker. Our government supports that.
Physical therapy i imagine is a money loser. It can take forever with complex problems 2-3 times per week. And now most PT places don’t have the time and are under mangled care so they can’t really help the complex long standing cases. Also it can require collaboration of which as we know is lacking.

http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

Also, many insurance plans limit the number of visits for Physical Therapy so much that it makes it impossible for someone to be able to go in the first place even if they wanted to go.

Suzi Q 38

Yes, my insurance limits the total visits per year, so I have to be very careful that the physical therapy is truly needed.
I have to view it as a teaching tool….that they teach me the exercises that I need to do at the gym or at home in order to feel better.

J Mac

And that is the exact problem with health care consumers today. No one wants to take the time to go to physical therapy and address the musculoskeletal component of their pain directly, but instead initiate opioid therapy. The ABIM recently recognized this paradigm shift and sensibly recommended 6 weeks of PT prior to radiographic imaging as a majority of low back pain (one of the primary culprits behind chronic pain issues) is related to musculoskeletal rather than discogenic or neurogenic issues. In addition, while insurance may not pay for every visit (usually a monthly limit), it is then in the hands of the health care consumer (more and more a director of care) to choose between paying out of pocket for proven direct care vs a life of escalating opioid therapy.

drg

the piece about press ganey scores is very sad. For one thing, patients opinions are important in the sense of being unhappy. But WHAT they are unhappy about is likely the overall care and knowing they are not getting their needs met. Since in many way patients are like children. they really don’t know all the time what they need. They just want to be taken care of and when they are not they cry.

A parent that just gives in to the crying child is letting the child be the parent. A crying child demanding that their parent buys them a certain toy for example is not really getting what they want. They may be needing a certain kind of attention that is lacking.

Same with patients. They are not doctors. They are smart enough to know their needs are not met. But they don’t know what needs to happen. Doctors giving in is letting the patients take charge of their care out of feeling threatened as stated. Under these circumstances no doctor is allowed to do their job out of fear. There is no support for doing the right thing. The government in this way as pointed out is doing a huge disservice. It is like lip service to unhappy patients.

http://twitter.com/NYCPatient NYC Patient

As a patient, this is VERY well put. Wow. Perfect analogy!

drg

thank you. I responded to your personal blog as well.

Suzi Q 38

You are so right. I am so happy to say that I don’t need Norco at this time, 4-5 weeks after my anterior discectomy. I kept trying to wean myself off of the Norco, starting at week 2. I just took less and less, and replaced it with straight Tylenol.
My neck brace is holding my head and neck in place, though. If I feel achy or in pain, I try 1/2 or 1 tablet (500 mg) of Tylenol. Sometimes, I try nothing.
I have read about the dependency possibilities, and luckily my pain has not been that profound for now. I try to work through it.
I loved it for going to sleep at night, but I decided to do without it.

drg

I’m not sure if the opiates for pain are all bad. Although I suppose there are disputes about that. I think it is the way it is being prescribed by some as if telling the patient that it is the solution in and of itself–whether that is said or not. If there is not a sufficient diagnosis and treatment plan to address, this is where it hurts patients.

Suzi Q 38

I have had two surgeries in two years. Both times, I was just given opiates as first line therapy.
Why not give me something else that is far less addicting?
I really don’t care what it is.

http://twitter.com/NYCPatient NYC Patient

Yes, but the average person is not aware or concerned about forming a dependency – they are just about relieving their pain. Post-op pain is indescribable. But, since I’ve seen the horrific results of addiction, I have always been very conservative with the meds as well.

After my L4-L5 discectomy, I was given percocet. I was in the hospital for 2 days. When I went home and looked it up and discovered just what type of medication it was, I was VERY deliberate on when I took it. 8 days post-op I stopped taking it even at night.

After a recent open liver surgery, much more painful then the spine, I was prescribed dilaudid. 6 days in the hospital. By the time I was discharged I would only take it twice a day – nurses tried getting me to take more. By day 10 post-op I stopped taking it at all and put the remaining abundance in an out-of-reach spot.

Doctors or nurses never recommended or advised, etc. To the contrary, they would recommend I take pain meds more than I was. Awareness is also part of the problem. There will still be those people who only want the drugs, but many addictions could be avoided if clear recommendations, guidelines, and SMALLER dispenses, were in place for patients.

f. lusu

part of the problem is that the parent doesn’t give the child the pertinent information. without knowledge, all they are left with is emotion. of course they become unhappy if a dr. just gives them a two minute summery of their condition, a script and maybe a pamphlet. ‘they really don’t know all the time what they need’. how can they know if it’s not explained? they sit in the exam room with growing anxiety and the dr comes in for a couple minutes and orders tests for a condition they don’t understand.the children are going to be very fussy because they have little control over things that might be scaring them. they might find out they have a serious condition that they may have to live with the rest of their life. they obviously have to deal with the emotional and physical pain at the same time, so the physical pain is given priority and swiftly medicated. the ‘children’ have to grow up very fast. if they have a serious condition, they have to find out what ‘needs to happen’ and be willing to take care of themselves between appointments. they don’t have to be dr.s, but they need to know what questions to ask. the more knowledge they have the less the ‘parent’ has to explain and they will know that a dr doesn’t always need an expensive test or the newest medication they see on a TV commercial. if they have a serious condition they need to use every opportunity to study about their disease or condition to be able to ask the right questions and not waste the dr.s time on minutia. because of the opioid problem,dr.s should provide a list of web sites for the patient to view so they can really understand the reality of drug dependence.

Daniel

Gabapentin should not be so costly for patient C. If a Costco Pharmacy is available, gabapentin 300mg #30 is available for $9. If no Costco is available, I estimate the insurance copay to be around $12 to $18. (However, this difference doesn’t affect the article because the vignette can be changed so that the patient claims gabapentin causes a variety of unusual side effects.)

Suzi Q 38

I was told to take gabapentin for my neuropathies, but at the time I didn’t know why I had the neuropathies. I would hate to suppress serious symptoms with a drug when the doctors could not tell me why I had neuropathies. It also caused sleepiness (great at night) and weight gain….ditto for Lyrica.
My hands and feet still are numb and cold, but not as bad as before my c spine surgery. I have to check with the neuro to see if I would benefit from these drugs or can I just do without them.

Daniel

I apologize for my choice of words (“patient claims”). It is suspicious when *some* patients give a long list of drugs they can’t take except for a particular opioid. However, allowing that suspicion to become a general attitude negatively affects the care of all patients.

http://twitter.com/riotofcolor1 riotofcolor

Thank you for apologizing about your choice of words. I am one of those people who has a not very long list of drugs I cannot take, including common over-the-counter drugs, as well as the 2 synthetic opioids I was prescribed. I do not/did not want any other opioids following the horrendous experience with synthetic opioids. I’m not a chronic pain patient. Rather than suggest maybe seeing a specialist to check out my kidney & liver function to see if there is an underlying problem, I think I’m viewed with suspicion and the accompanying negative attitude, not taken seriously. My solution is to avoid doctors, preferring alternative treatment, like acupuncture.

I wasn’t all that surprised that acupuncture wasn’t mentioned in Dr. Gunter’s otherwise excellent post. In my experience, western medical providers show little interest in understanding how it works and are more likely to dismiss the practice as “just nerves”, “placebo effect”, and so on. That’s a shame.

I was happy to see yoga an tai chi included in the post. You can borrow yoga and tai chi videos from the public library. Although not as good as a class with a teacher, they can be very helpful and cost nothing. I think people would be more likely to try these alternatives if they are encouraged to do so by their physician. Reimbursement to the provider for borrowing a dvd from the library is nil though.

Richard Davidson at the University of Wisconsin Madison is doing some fascinating work on meditation that should also be an alternative to prescription opioids, behavioral psychology, and psychiatric drugs.

Suzi Q 38

I have never tried acupuncture. Does it work?

http://twitter.com/riotofcolor1 riotofcolor

Acupuncture works well for me. My clinic is exceptional however, so I can’t make a blanket generalization of all acupuncturists or clinics.

http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

Riotofcolor, that’s great that accupuncture works so well for you and that the clinic that you go to is so good. Unfortunately, accupuncture and numerous other alternative treatments are out of the reach of many because the cost for them is too prohibitive. Not all insurance cover these modalities either, so those that would most likely benefit from them are not able to make use of them.

http://twitter.com/riotofcolor1 riotofcolor

Yes, it is unfortunate that acupuncture isn’t more widely available and accessible. It is also unfortunate that medical insurance doesn’t usually cover alternative treatment. I pay out of pocket, but don’t go very often – mostly an annual tune-up. Since more and more policies have co-pays, I’d much rather spend my co-pay dollars at a clinic that helps me, in an atmosphere free of suspicion and mistrust.

Suzi Q 38

What are some drugs that are decent alternatives to the opioids, that are not so addicting?

http://twitter.com/MakeThisLookAwe MakeThisLookAwesome

Hold up… what if those opioid medications actually *work* and get someone off disability? Are they really so awful then? The opioid isn’t the end of the story. Just prescribing it isn’t a bad thing. You’ve got to look at the larger picture about quality of life and symptom management.

J Mac

Opioids by their very nature are not a long term medication. Over time there will be a tolerance to the medication which is the problem. Quality of life and symptoms management need to target the nature of the pain, not escalating doses of opioids.

Suzi Q 38

Yes, one story on the news had a business executive taking 8 Norco a day and it wasn’t enough.
He was also taking other drugs for a synergistic effect.
He said that he wished that he just tried to tackle the back pain physically, with PT and/or surgery if necessary, rather than mask the pain with drugs. He admits that he is now an “addict.”

Stories like this scare me.

Suzi Q 38

If it is not a long term solution, what is the maximum length of time a patient should be using it…. 3 or 4 months?

Suzi Q 38

Yes, but at what price? True, it is fantastic that someone can continue to work instead of suffering at home in pain. On the other hand, if the opiate is causing dependency that is escalating with time, this is not good.
The pain needs to be addressed in a more direct way, or other drugs need to be tried that are considered less addicting.
There are probably a thousand drugs (i truly have no idea) that would work for pain. Most pain drugs work.
It is not an antibiotic that needs to cover a certain organism like staph or streph.
There must be other, less addicting alternatives.

f. lusu

they see any patient taking opioids long term ,and the dr. prescribing them long term. for certain patients, as part of the ‘problem’. perhaps it’s social suicide to step up and support the use of those drugs for legitimate use.

f. lusu

correct. not only is work productive, it’s a way to help with the self esteem and depression issues caused by living with never ending pain that ruins peoples lives. having a GP give those medications out to established patients, who actually need them, might be ideal. the GP would have seen their ongoing struggles with certain conditions and know that not only is the patient not lying to get drugs, the patient is in need of those drugs. so perhaps,for those patients, drug tolerance vs quality of life wouldn’t cause such a conflict of ‘first do no harm’. the GP would be able to monitor the overall health, instead of the 5 minute drug check the patient gets from a specialist once a month; who has to view every new patient as a potential drug seeking liar and might under treat the pain.. patients might feel safer having honest discussions with their GP about any pain med problem and not have to worry about losing access to medication. if the patient is out of options, they might end up at a pain clinic. they will have substandard care and a greater chance of addiction. ‘pain management specialists’ are the only legit option for many people because other dr.s are not willing to lose their license by getting involved with opioids.

dirgni

From my limited understanding, I believe a small amount of naltrexone along with the opiod is an inexpensive and effective way to mitigate the addictive qualities.

de Rerum Natura

Thanks for a great article. I wish PT were more easily affordable and available to all. I’m a Kaiser NorCal patient, and when I went in for patellofemoral syndrome, my primary care doc had a physical therapist available for office visit consults; he came in during the visit and showed me the right stretches and exercises to use. Kaiser covers all the costs of their patients’ care so it’s in their interest to have me get what I need when I need it. I hope accountable care organizations will be a step in this direction for the fee for service model. – Susan

buzzkillerjsmith

I’m interested in the idea of limiting by law opioids prescriptions from the ED but can see this causing even more ED visits. How’s that working out in New York?
ER docs are in a tough spot. I still can’t figure out why anyone would want to do that for a living.

From a PCP’s standpoint I can tell you that practices with a large number of chronic pain pts are absolutely miserable. The paperwork, the phone calls, the pt anger. I foolishly blundered into one years ago in Oregon and left after 2 years. Our clinic does not prescribe opioids for chronic pain–period. If you want that, find a new doc.

D Mgikarp

Sorry but I tried it all, and I still need opiates. I had a bulging disk at L5/S1. I went to the neuro surg. at my work (accredited hosp and level 1 trauma). The neuro was insisted I needed surgery. No physical therapy, nothing else recomended he wanted said discetomy and two level fusion. I went along with the surgery in 2009. During the surgery he miss drilled at L4, into my spinal cord. Didn’t know he was off from where he was supposed to be and threw on of six titanium screws in. After my CSF started leaking out he found out he messed up. Pulled the screw out and threw in some medtronics bone grafting material. Which later formed a spike 1/2 way through my spinal cord. Along with the numerous nerve damage that occurred during surgery and the spinal cord injury I am left unable to work, for the left of my life. I had to retire at 33 because the neuro surgeon didn’t know what he was doing. I am in severe constant pain. After surgery PT did no good. Along with the other stuff I tried, I was now totally screwed. Four years post-op I take (3) 100mg MsContin per day along with (4) 15 mg Morphine sulphate IR per day. Not my choice. And if I went to a doc office that said, “we don’t prescribe opioids period, no matter what. I would know you were all heartless a**holes. I sure didn’t ask for chronic pain, and if you want to treat me like an addict fine, that is your choice. But again I never asked for this guy to partially paralyze my right leg and destroy half my nerves at L4 just so I can get morphine. Only treatment I ever refused is steroid injections in my spinal cord. I got enough shooting stabbing pains without the need for spinal taps or needles in my back. I’ll take my opioids and you can think what you want. Without them my BP is 200/108 average and I would rather die then suffer like that. I just told my doc I’m not quitting smoking either. Why would I want to quit smoking so I can live to be in even more pain? Degenerative disk disease and also mild scoliosis are other fun things that occurred post-op, along with more bulging disks higher up in the C spine. So feel free to label me as a drugged out patient. And PS I am licensed in MI to smoke pot as well, so go ahead, add that label to the list. Opioid/pothead. But until you have walked in my shoes, you have no clue what pain is. If you don’t think opioids are absolutely necessary then why have they been used hundreds of years? And to that, if you like to judge people, I sure hope you have SEVERE chronic pain, and I sure hope you get treated just like I do. So psycho analyze that, and I hope your surgeon knows where the center of your spine is versus the side, because it could just happen to you too. And btw I was unable to sue him because no one would testify against the creep. He is still practicing and since he messed me up he paralyzed a young mother with 3 toddlers… After she freaked out because her legs no longer work, he said “that was a risk you took, you signed the waiver”. And no one can/or will stop him. My insurance paid him 120K to put me on disability and opioids for the rest of my life, and to this day he is doing 3-4 “surgerys” per week. I hope that the “pain” doctor that wrote this reads my reply. Sounds like you don’t know what pain is after all. After all I must just want to be nauseated and constipated constantly so I can get high. Get a life, and maybe you should better educate yourself about what pain is instead of writing about how I just want to get high. pffft. I hope you are able to suffer with chronic pain. If you want to be on Morphine just go see Neurosurgeon Dr. Alain Fabi at Bronson Methodist Hospital in Kalamazoo, MI. Let him butcher your low-back and enjoy the permanent disability and chronic back pain. Loads of fun, yeah. pfffffft. And all of you that think opiodis are never nessecary, shame on you too.

Drugged out on Opioids and cannabis, Yours Truly,

D

drg

I am very sorry for what you have been through. You know you bring up a very important issue that I see is NOT getting addressed in medicine–Failed Back Surgeries. Obviously you had a horrific experience but I am sure there are other patients who have had similar problems or even — not necessarily the fault of the surgeon–just surgeries that fail. It does not seem like there is a place for patients to get heard and as you say where do they go? I WISH YOU THE BEST AND I AM SORRY FOR WHAT YOU HAVE BEEN THROUGH AND yes of course i am glad they give you some relief.

dfjakl

You know how I know your story is fake? Your spinal cord doesn’t extend down to L4. In adults, the spinal cord only goes down to about L1 and maybe L2.

So, obviously no one drilled into your spinal cord. Cool story, bro.

Suzi Q 38

Harsh. What if his story is real.

Suzi Q 38

So sorry. People wonder why I had to get 3 opinions from neurosurgeons before I decided to proceed with my upper c spine surgery.
It is a HUGE risk.
I couldn’t believe the first surgeon: “What is the hesitation with scheduling your surgery with me??”
The hesitation for me was NOT his education or skills, but the shock of needing a surgery needed to sink in, and I needed another opinion!

The surgeons can tell you all they want about how routine your surgery will be for them, but the reality is that they truly do not know all that they will find. The wrong move here to there….could render you a para or quadriplegic.

In the end, I finally had to trust the knowledge of the 2 neurosurgeons, 1 orthopedic neurosurgeon (family friend) 2 neurologists, 1 MS neurologist (with fellow and medical student in tow), 1 gastroenterologist and my PCP of 10+years to tell me to:”Go schedule my surgery.” It was hard to trust someone with my future mobility. I am still not sure that I got the best surgeon. All I know is that he was a good one.
I remember that I thought of just living with the pain, but the uncertainty about walking scared the heck out of me.

Suzi Q 38

Unfortunately, a surgeon telling you that you need surgery is not unusual. That is what they do. They like to cut.
Maybe you needed it, maybe you didn’t. Have you complained to the medical board at your state of residence?
Have to contacted your patient advocacy department at the hospital and the joint commission?
I have learned that while I may have needed my surgery, I will need to make sure first. A lot can happen during a surgery. I would have died from infection or the anesthesia alone.

It is for this reason that no surgeon will be able to do surgery on me from now on unless a specialist (neuro, gastro, etc.) or my PCP tells me it is absolutely indicated and necessary.

On the other hand if it is a surgical emergency, that is different.

f. lusu

have you reported this dr?

Suzi Q 38

My MS specialist told me that I am still in “limbo” but he wants me to fully rid myself of the Norco ASAP.
It has been about 6 weeks since my surgery and I take 1/2 tablet at night about twice a week. I will try to take Tylenol instead all of the time.

K.A.

Provocative article. Good read. Many patients are stuck in a purely biomedical model for pain management when their care requires a multidisciplinary approach that embraces a biopsychosocial model.

http://www.facebook.com/davidtexpts David Browder

As a physical therapist, I can’t tell you how great it is to hear conservative care featured so prominently in this discussion. I couldn’t agree more – the evidence for early physical therapy is excellent for preventing chronic pain conditions… and also key in treating chronic pain. Direct access to physical therapy (allowing easier access), reducing copays to manageable levels (currently often at a specialist rate for a treatment that often requires 10-12 visits) and easing of regulatory burdens would go a long way towards helping with this problem. Thanks Dr. Gunter for the wisdom in this blog post.